Job Description

Resp & Qualifications

PURPOSE:
Triage and develops case leads for the department, using various data sources and employing statistical analysis and reporting skills.

ESSENTIAL FUNCTIONS:

Reactively perform triage on calls, tips, alerts, and gathers, compiles and interprets data from internal and external data bases and systems to support leads. Analyzes detailed claims files and performs financial calculations to assess financial impact of potential cases.

Proactively conduct research and analysis support for the department and to develop, prioritize and manage new case leads for potential assignment leads. Track incoming fraud allegations from all sources for statistical purposes and enter cases accurately in Fraud, Waste and Abuse case management system. Monitor and notify SIU associates on dollar recovery and Corrective Action Plan status.

Pursues low complexity and routine investigations of fraud and/or abuse theory approach analyses, provider and subscriber medical data, claims, and systems\' reports as required.

Performs root cause analysis to identify control deficiencies, and/or non-compliance as relates to risk mitigation and effective external/internal controls for CareFirst Business Operations.

Confirm aberrant billing, creates high level case synopsis for investigators or assigned cases, recommends solutions and proposes appropriate changes in department systems/procedures to expedite the workflows.

Maintains case file documentation to preserve as potentially discoverable material. Begins and maintains liaisons with the appropriate agencies.

Under direction from management, assists with updating and providing anti-fraud training to Company employees.

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Experience: 3 years years\' experience in a) claims processing, b) customer service function or equivalent experience in investigative, health care, nursing, law enforcement or insurance.

Preferred Qualifications: Credentials as Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC). In depth knowledge of corporate and divisional policies and procedures, claims processing, underwriting, medical policies, enrollment and billing and/or other related systems and procedures to determine the integrity of claims\' payments and business operations within CareFirst or previous experience in the health care industry.

Knowledge, Skills and Abilities (KSAs)

• Good working knowledge of PC skills.
• Excellent oral/written communication and interpersonal skills.
• Highly motivated, with strong drive, team spirit and organizational skills.
• Ability to prioritize multiple tasks to meet established deadlines and satisfy internal and external customer\'s demands.
• Ability to work effectively both independently and as a team-member.
• Proven judgment, analytical, decision making and problem-solving ability.
• Effectively interact with internal and external associates at all levels.
• Dependable, with the highest level of integrity.
• Ability to work well under pressure while assuming a leadership role.
• Demonstrate ability to comprehend Federal/State law and desire to further knowledge with additional education.

Salary Range: $47,232 - $86,592

Salary Range Disclaimer

Salary will be based on education, location, experience, certifications, etc. In addition to your salary, CareFirst offers benefits such as a comprehensive benefits package, incentive and recognition programs, and 401k contribution (all benefits are subject to eligibility requirements).

Department

Department:

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply:

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.

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